MEDICAL HISTORY FORM

Full Name
*

First Name Last Name

Best Contact Number
*

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Area Code Phone Number

Date of Birth
*

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Month
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Day Year

Sex

Female Male

Although dental professionals primarily treat the area in and around your mouth, your mouth is part of your entire body. Health problems that you may have, or medication that you may be taking, could have an important interrelationshop with the dentistry you will receive. Thank you for answering the following questions